A nurse is collecting data from a client who is 24 hours postpartum.
Which of the following findings should the nurse expect?

Choice A rationale:

Oxytocin is a hormone that causes the uterus to contract. It is often given to women after childbirth to help the uterus return

to its normal size and to prevent heavy bleeding. Therefore, monitoring the consistency of the fundus (the upper part of the

uterus) is an effective way to evaluate the effectiveness of this medication.

Choice B rationale:

While urinary output is an important vital sign to monitor in all patients, it is not directly related to the effectiveness of

Oxytocin. Oxytocin does not have a significant effect on urinary output.

Choice C rationale:

Blood pressure is another vital sign that should be monitored in all patients. However, it is not the primary indicator of

Oxytocin’s effectiveness. While Oxytocin can cause blood pressure changes, these are usually transient and not the primary

intended effect of the medication.

Choice D rationale:

Heart rate, like blood pressure and urinary output, is an important vital sign to monitor in all patients. However, it is not the

primary indicator of Oxytocin’s effectiveness. Oxytocin does not have a significant direct effect on heart rate.

Choice A rationale:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.